YOUR

IN PREGNANCY
What should you eat? Foods to avoid Preparing food Vitamins and minerals Vegetarian, vegan and special diets 24 26 26 27 28 Smoking Alcohol Pills, medicines and other drugs Illegal drugs X-rays 30 32 33 33 34 Keeping active Infections Inherited conditions Work hazards Flying and travel 34 36 38 39 39

HEALTH

A healthy diet and lifestyle can help you to keep well during pregnancy and give your baby the best possible start in life. This chapter explains some of the things you can do to stay healthy.

WHAT SHOULD YOU EAT?

A healthy diet is very important if you are pregnant or trying to get pregnant. Eating healthily during pregnancy will help your baby to develop and grow and will help to keep you fit and well. You dont need to go on a special diet, but make sure that you eat a variety of different foods every day in order to get the right balance of nutrients that you and your baby need. You should also avoid certain foods see Foods to avoid on page 26. You will probably find that you are more hungry than normal, but you dont need to eat for two even if you are expecting twins or triplets. Have breakfast every day this will help you to avoid snacking on foods that are high in fat and sugar. You may have to change the amounts of different foods that you eat, rather than cutting out all your favourites. More information Visit www.eatwell.gov.uk for useful information on what you should eat when you are pregnant or trying for a baby. The leaflets Eating while you are pregnant and Thinking of having a baby? are also available in several languages. Both leaflets are available online at www.food.gov.uk or can be ordered on 0845 606 0667.

delicious
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nutritious and

The eatwell plate

The eatwell plate below shows how much of each type of food you need to have a healthy and well balanced diet.
Fruit and vegetables
As well as vitamins and minerals, fruit and vegetables provide fibre, which helps digestion and prevents constipation. Eat at least five portions of fresh, frozen, canned, dried or juiced fruit and vegetables each day. Always wash them carefully. To get the most out of vegetables, eat them raw or lightly cooked. For more information and portion sizes, visit www.5aday.nhs.uk

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YOUR HEALTH IN PREGNANCY

Bread, rice, potatoes, pasta and other starchy foods

Carbohydrates are satisfying without containing too many calories, and are an important source of vitamins and fibre. They include bread, potatoes, breakfast cereals, pasta, rice, oats, noodles, maize, millet, yams, cornmeal and sweet potatoes. These foods should be the main part of every meal. Eat wholegrain varieties when you can.

Meat, fish, eggs, beans and other non-dairy sources of protein

Protein includes meat (except liver), fish, poultry, eggs, beans, pulses and nuts (for information on peanuts see page 112). These foods are all good sources of nutrients. Eat moderate amounts each day. Choose lean meat, remove the skin from poultry and cook using only a little fat. Make sure eggs, poultry, pork, burgers and sausages are cooked all the way through. Check that there is no pink meat and that juices have no pink or red in them. Try to eat two portions of fish a week, one of which should be oily fish. There are some fish that you should avoid see Foods to avoid on page 26 for more information.

Foods and drinks that are high in fat and/or sugar

This food group includes all spreading fats, oils, salad dressings, cream, chocolate, crisps, biscuits, pastries, ice cream, cake, puddings and fizzy drinks. You should only eat a small amount of these foods. Sugar contains calories without providing any other nutrients that the body needs. Having sugary foods and drinks too often can cause tooth decay, especially if you have them between meals. If we eat more than we need, this can lead to weight gain. Eating more fatty foods is likely to make you put on weight. Having too much saturated fat can increase the amount of cholesterol in the blood, which increases the chance of developing heart disease. Try to cut down on food that is high in saturated fat and have foods rich in unsaturated fat instead.

Milk and dairy foods

Dairy foods like milk, cheese, yoghurt and fromage frais are important because they contain calcium and other nutrients that your baby needs. Eat two or three portions a day, using low-fat varieties whenever you can for example, semi-skimmed or skimmed milk, low-fat yoghurt and half-fat hard cheese. However, there are some cheeses that you should avoid see Foods to avoid on page 26 for more information.

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FOODS TO AVOID
There are some foods that you should not eat when you are pregnant because they may make you ill or harm your baby. You should avoid: Some types of cheese. Dont eat mould-ripened soft cheese, like Brie, Camembert and others with a similar rind. You should also avoid soft blue-veined cheese, like Danish blue. These are made with mould and they can contain listeria, a type of bacteria that can harm your unborn baby. Although listeriosis is a very rare infection, it is important to take special precautions during pregnancy because even the mild form of the illness in the mother can lead to miscarriage, stillbirth or severe illness in a newborn baby. You can eat hard cheeses such as cheddar and parmesan, and processed cheeses made from pasteurised milk such as cottage cheese, mozzarella and cheese spreads. Pt. Avoid all types of pt, including vegetable pts, as they can contain listeria.

Raw or partially cooked eggs. Make sure that eggs are thoroughly cooked until the whites and yolks are solid. This prevents the risk of salmonella food poisoning. Avoid foods that contain raw and undercooked eggs, such as homemade mayonnaise. Raw or undercooked meat. Cook all meat and poultry thoroughly so that there is no trace of pink or blood. Take particular care with sausages and minced meat. It is fine to eat steaks and other whole cuts of beef and lamb rare, as long as the outside has been properly cooked or sealed. Liver products. Dont eat liver, or liver products like liver pt or liver sausage, as they may contain a lot of vitamin A. Too much vitamin A can harm your baby. Supplements containing vitamin A. Dont take highdose multivitamin supplements, fish liver oil supplements or any supplements containing vitamin A. Some types of fish. Dont eat shark, marlin and swordfish, and limit the amount of tuna you eat to no more than two tuna steaks a week (about 140g cooked or 170g raw each) or four mediumsized cans of tuna a week (about 140g when drained). These types of fish contain high levels of mercury, which can damage your babys developing nervous system. Dont eat more than two portions of oily fish per week. Oily fish includes fresh tuna (but not canned tuna), salmon, mackerel, sardines and trout. Raw shellfish. Eat cooked rather than raw shellfish as they can contain harmful bacteria and viruses that can cause food poisoning. Peanuts. If you would like to eat peanuts or foods containing peanuts (such as peanut butter) during pregnancy, you can choose to do so as part of a healthy

balanced diet, unless you are allergic to them or your health professional advises you not to. You may have heard that some women have, in the past, chosen not to eat peanuts when they were pregnant. This is because the government previously advised women that they may wish to avoid eating peanuts during pregnancy if there was a history of allergy in their childs immediate family (such as asthma, eczema, hayfever, food allergy or other types of allergy). But this advice has now been changed because the latest research has shown that there is no clear evidence to say if eating or not eating peanuts during pregnancy affects the chances of your baby developing a peanut allergy. Unpasteurised milk. Drink only pasteurised or UHT milk which has been pasteurised. If only raw or green-top milk is available, boil it first. Dont drink unpasteurised goats or sheeps milk or eat certain food that is made out of them, e.g. soft goats cheese.

Your weight
Most women gain between 10kg and 12.5kg (2228lb) while pregnant. Weight gain varies a great deal and depends on your weight before pregnancy. Much of the extra weight is due to the baby growing. Putting on too much weight can affect your health and increase your blood pressure. Equally, it is important that you do not diet, but eat healthily. Try and stay active by keeping up your normal daily activity or exercise. If you are concerned, talk to your midwife or GP. They may give you advice if you weigh more than 100kg (about 15 stone) or less than 50kg (about 8 stone).

PREPARING FOOD
Wash fruit, vegetables and salads to remove all traces of soil, which may contain toxoplasma. This can cause toxoplasmosis, which can harm your baby (see page 37). Heat ready-meals until they are piping hot all the way through. This is especially important for meals containing poultry. Keep leftovers covered in the fridge and use within two days. Wash all surfaces and utensils, and your hands, after preparing raw meat. This will help to avoid infection with toxoplasma.
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VITAMINS AND MINERALS

Eating a healthy, varied diet will help you to get all the vitamins and minerals you need while you are pregnant. There are some vitamins and minerals that are especially important: Folic acid. Folic acid is important for pregnancy as it can reduce the risk of neural tube defects such as spina bifida. If you are thinking about getting pregnant, you should take a 400 microgram folic acid tablet every day until you are 12 weeks pregnant. If you did not take folic acid before you conceived, you should start as soon as you find out that you are pregnant. You should also eat foods that contain folic acid, such as green leafy vegetables, fortified breakfast cereals and brown rice. Some breakfast cereals, breads and margarines have folic acid added to them. If you already have a baby with spina bifida, or if you have coeliac disease or diabetes or take anti-epileptic medicines, ask your GP or midwife for more advice. You will need to take a bigger dose of folic acid.

More information For more information about folic acid, read Folic acid: An essential guide for making babies at www.breastfeeding.nhs.uk/en/ materialforclients/dl_13.asp Foods carrying the mark on the right have added folic acid.

The best source of vitamin D is summer sunlight. The amount of time you need in the sun to make enough vitamin D is different for every person and depends on things like skin type, time of day and time of the year. But you dont need to sunbathe: the amount of sun you need to make enough vitamin D is less than the amount that causes tanning or burning. If you have dark skin or always cover your skin, you may be at particular risk of vitamin D deficiency. Talk to your midwife or doctor if you are worried about this. (See also Vitamin supplements on page 28.) Iron. If you are short of iron, you will probably get very tired and you can become anaemic. Lean meat, green, leafy vegetables, dried fruit and nuts (see page 26 about avoiding peanuts) all contain iron. Many breakfast cereals have iron added. If the iron level in your blood becomes low, your GP or midwife will advise you to take iron supplements. These are available as tablets or a liquid. Vitamin C. You need vitamin C as it may help you to absorb iron. Citrus fruits, tomatoes, broccoli, peppers, blackcurrants, potatoes and some pure fruit juices are good sources of vitamin C. If your iron levels are low, it may help to drink orange juice with an iron-rich meal. Calcium. Calcium is vital for making your babys bones and teeth. Dairy products and fish with edible bones like sardines are rich in calcium. Breakfast cereals, dried fruit such as figs and apricots, bread, almonds, tofu (a vegetable protein made from soya beans) and green leafy vegetables like watercress, broccoli and curly kale are other good sources of calcium.

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YOUR HEALTH IN PREGNANCY

Vitamin D. You need vitamin D to keep your bones healthy and to provide your baby with enough vitamin D for the first few months of their life. Vitamin D regulates the amount of calcium and phosphate in the body, and these are needed to help keep bones and teeth healthy. Deficiency of vitamin D can cause childrens bones to soften and can lead to rickets. You should take a supplement of 10 micrograms of vitamin D every day. Only a few foods contain vitamin D, including oily fish like sardines, fortified margarines, some breakfast cereals and taramasalata.

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Vitamin supplements
It is best to get vitamins and minerals from the food you eat, but when you are pregnant you will need to take some supplements as well: 10 micrograms of vitamin D throughout your pregnancy and if you breastfeed. 400 micrograms of folic acid ideally this should be taken from before you get pregnant until you are 12 weeks pregnant. If you are vegetarian or vegan, you may need to take a vitamin B12 supplement as well as other supplements. Talk to your doctor or midwife about this. If you have a special or restricted diet, you may need additional supplements. Talk to your doctor or midwife about this. Do not take vitamin A supplements, or any supplements containing vitamin A, as too much could harm your baby. Which supplements? You can get supplements from pharmacies and supermarkets or your GP may be able to prescribe them for you. If you want to get your folic acid or vitamin D from a multivitamin tablet, make sure that the tablet does not contain vitamin A (or retinol). Healthy Start vitamins for women contain the correct amount of folic acid and vitamin D and are free from the NHS without a prescription to pregnant women receiving Healthy Start vouchers. Ask your GP or pharmacist for advice if you are unsure (see Healthy Start on this page). Your primary care trust and local pharmacies may sell this supplement to women who dont receive it free.
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Healthy Start
Healthy Start is a scheme that provides vouchers that can be exchanged for milk, fresh fruit and vegetables and infant formula milk. You can also receive free vitamins. You qualify for Healthy Start if you are pregnant or have a child under four years old, and you and your family receive one of the following: Income Support. Income-based Jobseekers Allowance. Child Tax Credit and have an annual family income of 16,040 or less (2008/09). Working Tax Credit run-on (but not Working Tax Credit). Working Tax Credit run-on is the Working Tax Credit you receive in the four weeks immediately after you have stopped working for 16 hours or more per week. Or you qualify if you are pregnant and under 18 years of age. You can receive vouchers that are worth 3.10 per week or 6.20 per week for children under one year old. For further information: Pick up the Healthy Start leaflet HS01, A Healthy Start for Pregnant Women and Young Children from your local health centre or call 0845 607 6823 to request a free copy. Ask your health visitor for more information. Visit www.healthystart.nhs.uk

VEGETARIAN, VEGAN AND SPECIAL DIETS

A varied and balanced vegetarian diet should give enough nutrients for you and your baby during pregnancy. However, you might find it hard to get enough iron and vitamin B12. Talk to your doctor or midwife about how you can make sure that you are getting enough of these important nutrients. You should also talk to your doctor or midwife if you have a restricted diet because you have a food intolerance (such as coeliac disease) or for religious reasons. Ask to be referred to a dietician who can give you advice on how to get the nutrients you need for you and your baby. More information For further information, visit: the Vegetarian Society website at www.vegsoc.org the Vegan Society website at www.vegansociety.com

Healthy snacks
You may find that you get hungry between meals. Avoid snacks that are high in fat and/or sugar. Instead you could try the following: Fresh fruit. Sandwiches or pitta bread filled with grated cheese, lean ham, mashed tuna, salmon or sardines and salad.

Caffeine
High levels of caffeine can result in babies having a low birth weight, which can increase the risk of health problems in later life. Too much can also cause miscarriage. Caffeine is naturally found in lots of foods, such as coffee, tea and chocolate, and is added to some soft drinks and energy drinks. It can also be found in certain cold and flu remedies. Talk to your midwife, pharmacist or another health professional before taking these remedies. You dont need to cut caffeine out completely, but you should limit how much you have to no more than 200mg a day. Try decaffeinated tea and coffee, fruit juice or water and limit the amount of energy drinks, which may be high in caffeine. Dont worry if you occasionally have more than this, because the risks are quite small. Caffeine content in food and drink 1 mug of instant coffee: 100mg 1 mug of filter coffee: 140mg

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YOUR HEALTH IN PREGNANCY

Salad vegetables. Low-fat yoghurt or fromage frais. Hummus and bread or vegetable sticks. Ready-to-eat apricots, figs or prunes. Vegetable and bean soups. Unsweetened breakfast cereals or porridge and milk. Milky drinks or unsweetened fruit juices. Baked beans on toast or a baked potato.

1 mug of tea: 75mg 1 can of cola: 40mg 1 can of energy drink: up to 80mg 1 x 50g bar of plain chocolate: up to 50mg 1 x 50g bar of milk chocolate: up to 25mg So if you eat... one bar of plain chocolate and one mug of filter coffee two mugs of tea and one can of cola, or one mug of instant coffee and one can of energy drink you have reached almost 200mg of caffeine.

healthy

options

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Help and support

Getting help with stopping smoking

SMOKING
Every cigarette you smoke harms your baby. Cigarettes restrict the essential oxygen supply to your baby. So their tiny heart has to beat harder every time you smoke. Cigarettes contain over 4,000 chemicals. Protecting your baby from tobacco smoke is one of the best things you can do to give your child a healthy start in life. Its never too late to stop.

If you stop smoking now

The Smokefree Pregnancy Support DVD will show you all the free NHS support available to help you to stop and stay stopped. To order your free DVD, call the NHS Pregnancy Smoking Helpline on 0800 169 9 169, or visit www.nhs.uk/smokefree The NHS Pregnancy Smoking Helpline on is open from 12pm to 9pm every day and offers free help, support and advice on stopping smoking when you are pregnant. You can also sign up to receive ongoing advice and support at a time that suits you. You can also ask your midwife, health visitor, practice nurse or pharmacist for advice and for the details of your local NHS Stop Smoking Service. They offer one-to-one or group sessions with trained stop smoking advisers and may even have a pregnancy stop smoking specialist. They can offer advice about dealing with stress, weight gain and nicotine replacement therapy to help you manage your cravings. Stopping smoking will benefit both you and your baby immediately. Carbon monoxide and chemicals will clear from the body and oxygen levels will return to normal.

0800 169 9 169

Stopping smoking action plan 1 Think

Think about: what you and your baby will gain if you stop smoking (see above) how much smoking costs you.

What else could you spend your money on? How can you treat yourself or your baby with the money you save?

What is keeping you smoking?

List your top five reasons for going smokefree; e.g. protecting your health or the health of your baby.
1 2 3 4 5

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If you stop smoking:

You will have less morning sickness and fewer complications in pregnancy. You are more likely to have a healthier pregnancy and a healthier baby. You will reduce the risk of stillbirth. You will cope better with the birth. Your baby will cope better with any birth complications.

Your baby is less likely to be born too early and have to face the additional breathing, feeding and health problems which often go with being premature (see Chapter 14). Your baby is less likely to be born underweight and have a problem keeping warm. Babies of mothers who smoke are, on average, 200g (about 8oz) lighter than other babies. These babies may have problems during and after labour and are more prone to infection.

You will reduce the risk of cot death (see page 129 for more information about how to reduce the risk of cot death). It will also be better for your baby later in life. Children whose parents smoke are more likely to suffer from illnesses which need hospital treatment (such as asthma). The sooner you stop, the better. But stopping even in the last few weeks of pregnancy will benefit you and your baby.

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YOUR HEALTH IN PREGNANCY

2 Get help
Take advantage of the free NHS support that is available to you. You are four times more likely to quit successfully with NHS support. See the Help and support box on the left for more information. Ask your friends and family to help and support you.

3 Prepare
If you understand why you smoke and what triggers your smoking, you will be able to prepare yourself so that you can cope when you quit. It can help to: give up with somebody else, so that you can support each other change the habits you associate with smoking, and plan how you will deal with difficult situations without the use of cigarettes. Choose a day to stop. Will the first few days be easier during a working week or over a weekend? When you are busy or relaxed? Whatever you choose, stop completely on that day. Review your plan and get rid of all of your cigarettes the day before your day for stopping. My chosen day for stopping smoking is:

4 Stop smoking
Lots of people start smoking again because they feel they cannot cope with the withdrawal symptoms. The first few days may not be much fun but the symptoms are a sign that your body is starting to recover. Take one day at a time and reward yourself for success. Go through your list of reasons for going smokefree to remind yourself why you have given up. If you have had a scan, use your scan images to keep you going through the times when you are finding it tough.
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Secondhand smoke
If your partner or anyone else who lives with you smokes, it can affect you and your baby both before and after birth. You may also find it more difficult to quit. Secondhand smoke can cause low birth weight and cot death. Infants of parents who smoke are more likely to be admitted to hospital for bronchitis and pneumonia during the first year of life, and more than 17,000 children under the age of five are admitted to hospital every year because of the effects of secondhand smoke.

Drinking is not just dangerous for the baby in the first three months: alcohol can affect your baby throughout pregnancy. And if you drink heavily during pregnancy, a particular group of problems could develop that are known as Fetal Alcohol Syndrome (FAS). Children with this syndrome have: restricted growth

ALCOHOL
When you drink, alcohol reaches your baby through the placenta. Too much exposure to alcohol can seriously affect your babys development. Because of this risk, pregnant women or women trying to conceive should avoid drinking alcohol. If you do choose to drink, then protect your baby by not drinking more than 1 to 2 units of alcohol once or twice a week, and dont get drunk. Additional advice from the National Institute for Health and Clinical Excellence (NICE) advises women to avoid alcohol in the first three months in particular, because of the increased risk of miscarriage. When you drink, alcohol passes from your blood, through the placenta, to your baby. A babys liver is one of the last organs to develop fully and does not mature until the latter half of pregnancy. Your baby cannot process alcohol as well as you can.

facial abnormalities learning and behavioural disorders. Drinking more than 1 to 2 units once or twice a week, as well as binge drinking, may be associated with lesser forms of FAS. The risk is likely to be greater the more you drink. If you are drinking with friends: find a non-alcoholic drink that you enjoy sip any alcohol you do drink slowly to make it last dont let people pressure you into drinking, and avoid getting drunk.

Help and support

What is a unit of alcohol?

One UK unit is 10ml, or 8g, of pure alcohol. A unit is:

Getting help with drinking

If you have difficulty cutting down what you drink, talk to your doctor, midwife, pharmacist or other healthcare professional. Confidential help and support is available from local counselling services (look in the telephone directory or contact Drinkline on 0800 917 8282). You should talk to your midwife if you have any concerns you have about your drinking around the time of conception and early pregnancy. You can get more advice from www.nhs.uk/units

or

or

1/2

pint of beer, lager or cider at 3.5% ABV

a single measure (25ml) of spirit (whisky, gin, bacardi, vodka, etc.) at 40% ABV

1/2 standard

(175ml) glass of wine at 11.5% ABV

To find out more about units, visit the Know Your Limits website at www.nhs.uk/units
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PILLS, MEDICINES AND OTHER DRUGS

Some medicines, including some common painkillers, can harm your babys health but some are safe, for example medication to treat longterm conditions such as asthma, thyroid disease, diabetes and epilepsy. To be on the safe side, you should: always check with your doctor, midwife or pharmacist before taking any medicine make sure that your doctor, dentist or other health professional knows you are pregnant before

they prescribe you anything or give you treatment talk to your doctor if you take regular medication ideally before you start trying for a baby or as soon as you find out you are pregnant, and use as few over the counter medicines as possible. Medicines and treatments that are usually safe include paracetamol, most antibiotics, dental treatments (including local anaesthetics), some immunisations (including tetanus and flu injections) and nicotine replacement therapy. But you should always check with your GP, pharmacist or midwife first.

ILLEGAL DRUGS
Illegal drugs like cannabis, ecstasy, cocaine and heroin can harm your baby. If you use any of these drugs, it is important to talk to your doctor or midwife so that they can provide you with advice and support to help you stop. They can also refer you for additional support. Some dependent drug users initially need drug treatment to stabilise or come off drugs to keep the baby safe. For more information, contact Narcotics Anonymous (see page 183) or talk to FRANK, the drugs information line, on 0800 77 66 00.

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YOUR HEALTH IN PREGNANCY

Medicines for minor ailments when pregnant

Make sure the medicine is safe to take when pregnant. For further information, speak to your pharmacist or NHS Direct on 0845 4647.
Minor ailment
Constipation Cough Diarrhoea Haemorrhoids (piles) Hayfever, house dust mite and animal hair allergy Head lice Indigestion Nasal congestion (stuffy or runny nose) Pain (e.g. headache, toothache)

First choice
Eat more fibre. Bulk laxatives that contain ispaghula. Honey and lemon in hot water. Simple linctus. Oral rehydration sachets. Soothing creams, ointments or suppositories. Antihistamine nasal sprays and eye drops. Steroid nasal sprays. Wet combing. Dimeticone lotion. Antacids (indigestion mixtures). Steam inhalation (e.g. over a bowl of hot water) or a hot shower. Paracetamol.

Second choice
On your doctors advice: bisacodyl or lactulose.

Do not use

Medicines that contain codeine, unless advised by your doctor. Loperamide. Ice pack. On your doctors advice: occasional doses of the antihistamines loratadine or chlorphenamine. If ineffective, head lice treatments containing malathion in water (aqueous lotion). On your doctors advice: medicines that reduce acid production, e.g. omeprazole. If severe, occasional doses of oxymetazoline or xylometazoline nasal spray. Ibuprofen may be taken in the 2nd trimester (weeks 14 to 27) but avoid taking it in the 1st or 3rd trimesters unless advised by your doctor. On your doctors advice: mebendazole, but preferably not in the 1st trimester. Phenylephrine or pseudoephedrine, especially in the 1st trimester. Medicines that contain codeine (e.g. co-codamol, co-dydramol, dihydrocodeine), unless advised by your doctor. Other antihistamines.

Threadworms

Pharmacists cannot supply threadworm medicines to pregnant women without a prescription. Pharmacists cannot supply medicines for vaginal thrush to pregnant women without a prescription.

Vaginal thrush

On your doctors advice: clotrimazole pessaries or cream. Do not use the pessary applicator if you are near term (at the end of your pregnancy).

Fluconazole.

Acknowledgement: United Kingdom Medicines Information (UKMi)

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Herbal and homeopathic remedies and aromatherapy

Not all natural remedies are safe in pregnancy. Contact the Institute for Complementary and Natural Medicine to make sure that your practitioner is qualified (see page 183). Tell your practitioner that you are pregnant, and tell your midwife or doctor and pharmacist which remedies you are using.

Exercises for a fitter pregnancy

Try to fit these exercises into your daily routine. They will strengthen your muscles so that you can carry extra weight, make your joints stronger, improve your circulation, ease backache and generally make you feel well. Stomach-strengthening exercises These strengthen your stomach (abdominal) muscles and ease backache, which can be a problem in pregnancy. As your baby gets bigger you may find that the hollow in your lower back becomes more pronounced, which can lead to backache. Start in a box position (on all fours), with your knees under your hips, your hands under your shoulders, your fingers facing forward and your stomach muscles lifted so that your back is straight.

Exercise tips
Exercise doesnt have to be strenuous to be beneficial. Make sure that you warm up and cool down. Try to keep active on a daily basis. Half an hour of walking each day can be enough. If you cannot manage that, any amount is better than nothing. Avoid any strenuous exercise in hot weather. Drink plenty of water and other fluids. If you go to exercise classes, make sure that your teacher is properly qualified and knows that you are pregnant and how far your pregnancy has progressed. You might like to try swimming, because the water will support your increased weight. Some local swimming pools provide aquanatal classes with qualified instructors.

X-RAYS
X-rays should be avoided in pregnancy if possible. Make sure that your dentist knows you are pregnant.

KEEPING ACTIVE
The more active and fit you are during pregnancy, the easier it will be for you to adapt to your changing shape and weight gain. It will also help you to cope with labour and to get back into shape after the birth. Keep up your normal daily physical activity or exercise (sport, dancing or just walking to the shops and back) for as long as you feel comfortable. Dont exhaust yourself, and remember that you may need to slow down as your pregnancy progresses or if your doctor advises you to. As a general rule, you should be able to hold a conversation as you exercise. If you become breathless as you talk, then you are probably exercising too strenuously. If you were inactive before you were pregnant, dont suddenly take up strenuous exercise. If you start an aerobic exercise programme, begin with no more than 15 minutes continuous exercise, three times per week. Increase this gradually to a maximum of 30-minute sessions, four times a week. Inform the instructor that you are pregnant.
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Exercises to avoid
Lying flat on your back particularly after 16 weeks. The bump presses on the big blood vessels and can make you feel faint. Contact sports where there is a risk of being hit, such as kickboxing, judo or squash. Horse riding, downhill skiing, ice hockey, gymnastics and cycling, because there is a risk of falling. Scuba diving, because the baby has no protection against decompression sickness and gas embolism. Exercising at heights over 2,500 metres until you have acclimatised. This is because you and your baby are at risk of acute mountain sickness (decrease in oxygen). Pull in your stomach muscles and raise your back up towards the ceiling, curling your trunk and allowing your head to relax gently forward. Dont let your elbows lock.

 Hold for a few seconds then slowly return to the box position. Take care not to hollow your back it should always return to a straight or neutral position. Do this slowly and rhythmically 10 times, making your muscles work hard and moving your back carefully. Only move your back as far as you can comfortably. Pelvic tilt exercises Stand with your shoulders and bottom against a wall. Keep your knees soft. Pull your belly button towards your spine, so that your back flattens against the wall. Hold for four seconds and release. Repeat up to 10 times. Pelvic floor exercises Pelvic floor exercises help to strengthen the muscles of the pelvic floor, which are placed under great strain in pregnancy and childbirth. The pelvic floor consists of layers of muscles which stretch like a supportive hammock from the pubic bone (in front) to the base of the backbone. During pregnancy you may find that you leak urine when you cough or strain. This is known as stress incontinence of urine and it can continue after pregnancy. By performing pelvic floor exercises, you strengthen the pelvic floor muscles and this helps to reduce or avoid this problem after pregnancy. It is important to do them even if you are young and not suffering from stress incontinence now.

Close up your back passage as if trying to prevent a bowel movement. At the same time, draw in your vagina as if you are gripping a tampon, and your urethra as if to stop the flow of urine. First do this exercise quickly tightening and releasing the muscles straight away. Then do it slowly, holding the contractions for as long as you can before you relax. Try to count to 10. Try to do three sets of eight squeezes every day. To help you remember, you could do them once at each meal. As well as these exercises, you will also need to practise tightening up the pelvic floor before and during coughing and sneezing. Ask your midwife or doctor about these exercises. Your local maternity unit should run classes where a specialist physiotherapist attends. They can instruct you in groups or individually. Feel free to ask them for advice and help.

Foot exercises Foot exercises can be done sitting or standing. They improve blood circulation, reduce swelling in the ankles and prevent cramp in the calf muscles. Bend and stretch your foot vigorously up and down 30 times. Rotate your foot eight times one way and eight times the other way. Repeat with the other foot.

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YOUR HEALTH IN PREGNANCY

To protect your back Sit up straight with your bottom against the back of your chair. Tuck a small cushion behind your waist if you wish. When you pick something up, bend your knees, not your back. Try to stand tall.

gentle exercise
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INFECTIONS
Rubella
If you catch rubella (or German measles) in the first four months of pregnancy it can seriously affect your babys sight and hearing and cause brain and heart defects. All children are now offered a vaccine against rubella through the MMR immunisation at 13 months and a second immunisation before they start school. If you are not immune and you do come into contact with rubella, tell your doctor at once. Blood tests will show whether you have been infected.

Sexually transmitted infections

Sexually transmitted infections (STIs) are on the increase. The most common is chlamydia. Up to 70% of women and 50% of men who have an STI show no symptoms, so you may not know if you have one. However, many STIs can affect your babys health during pregnancy and after birth. If you have any reason to believe that you or your partner has an STI, you should go for a check-up as soon as you can. You can ask your GP or midwife, or go to a genitourinary medicine (GUM) or sexual health clinic. You will be guaranteed strict confidentiality. You can find your nearest GUM clinic or sexual health clinic in your phone book listed under the name of your primary care trust or at www.nhsdirect.nhs.uk or you can call the Sexual Health Helpline free on 0800 567 123. If you are under 25, you can visit a Brook centre to get free, confidential advice. To find your nearest centre, visit www.brook.org. uk or call the Ask Brook national helpline on 0808 802 1234. You can contact the National Chlamydia Screening Programme for a free, confidential test. Visit www.chlamydiascreening.nhs.uk

HIV and AIDS

You will be offered a confidential HIV test as part of your routine antenatal care (see page 47). Your doctor or midwife will discuss, the test with you, and counselling will be available if the result is positive. You can also go to a GUM clinic for an HIV test and advice. Current evidence suggests that an HIV positive mother in good health and without symptoms of the infection is unlikely to be adversely affected by pregnancy. HIV positive mothers can pass on the virus through breastmilk. However, it is possible to reduce the risk of transmitting HIV to your baby during pregnancy and after birth (see box on page 47). If you are HIV positive, talk to your doctor about your own health and the options open to you, or contact the organisations listed on page 185 for advice and counselling.

More information For more information, read the information on screening tests in Chapter 4 or go to www.screening.nhs.uk

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medical advice

Hepatitis C
Hepatitis C is a virus that infects the liver. Many people with hepatitis C may have no symptoms and be unaware that they are infected. If you have hepatitis C, you might pass the infection to your baby, although the risk is much lower than with hepatitis B or HIV. This cannot be prevented at present. Your baby can be tested for hepatitis C. If they are infected, they can be referred for specialist assessment.

labour, a caesarean section may be recommended to reduce the risk of transmission to your baby.

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YOUR HEALTH IN PREGNANCY

Chickenpox
Around 95% of women are immune to chickenpox. If you have not had it and you come into contact with someone who has it, speak to your GP, midwife or obstetrician at once. A blood test will establish whether you are immune. Chickenpox infection in pregnancy can be dangerous for both mother and baby, so seek advice as soon as possible.

Hepatitis B
Hepatitis B is a virus that infects the liver. Many people with hepatitis B, will have no signs of illness, but they might infect others. If you have hepatitis B, or are infected during pregnancy, you can pass the infection to your baby at birth. You will be offered a blood test for hepatitis B as part of your antenatal care (see page 47). Babies who are at risk should be immunised at birth. This is 9095% effective in preventing them from getting hepatitis B and developing longterm infection. The first dose is given within 24 hours of birth and two more doses are given at one and two months, with a booster dose at 12 months. A few babies may also need an injection of hepatitis B immunoglobulin soon after birth. Your baby will be tested for hepatitis B infection at 12 months. Any babies who have become infected should be referred for specialist assessment and follow-up.

Herpes
Genital herpes infection can be caught through genital contact with an infected person or from oral sex with someone who has oral herpes (cold sores) and can be dangerous for a newborn baby. Initial infection causes very painful blisters or ulcers on the genitals. Less severe attacks usually occur for some years afterwards. If you or your partner are infected, use condoms or avoid sex during an attack. Avoid oral sex if either of you have cold sores or active genital herpes. Tell your doctor or midwife if either you or your partner have recurring herpes or develop the symptoms described above. If your first infection occurs in pregnancy, there is treatment available. If your first infection occurs towards the end of your pregnancy or during

Toxoplasmosis
This infection can damage your baby if you catch it during pregnancy, so take precautions (see page 38). Most women have already had the infection before pregnancy and will be immune. If you feel you may have been at risk, talk to your GP, midwife or obstetrician. If you do catch toxoplasmosis while you are pregnant, you can get treatment.

Parvovirus B19 (slapped cheek disease)

Parvovirus B19 infection is common in children and causes a characteristic red rash on the face, so it is often called slapped cheek disease. 60% of women are immune to this infection. However, parvovirus B19 is very infectious and can be harmful to your baby. If you come into contact with someone who is infected you should talk to your doctor, who can check whether you are immune through a blood test. In most cases, the baby is not affected when a pregnant woman is infected with parvovirus.

You can get infected with HIV, hepatitis B, or hepatitis C if you:

have sex with someone who is infected without using a condom use injectable drugs and share equipment with an infected person. You may have already been infected with hepatitis B if you were born or spent your childhood outside the UK in a country where hepatitis B is common. (You may have acquired the infection at birth.)

You may have been infected with hepatitis C if you:

received a blood transfusion in the UK prior to September 1991, or blood products prior to 1986 received medical or dental treatment in countries where hepatitis C is common and the infection is not controlled properly.

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Group B streptococcus
Group B streptococcus (GBS) is a bacterium carried by up to 30% of people which causes no harm or symptoms. In women it is found in the intestine and vagina and causes no problem in most pregnancies. In a very small number it infects the baby, usually just before or during labour, leading to serious illness. If you have already had a baby who had group B streptococcal infection, you should be offered antibiotics during labour to reduce the chances of your new baby getting the infection. If you have had a group B streptococcal urinary tract infection with GBS (cystitis) during the pregnancy, you should also be offered antibiotics in labour. Group B streptococcal infection of the baby is more likely if your labour is premature, your waters break early, you have a fever during labour or you currently carry GBS. Your midwife or doctor will assess whether you need antibiotics during labour to protect your baby from being infected. It is possible to be tested for GBS late in pregnancy if you have concerns. Talk to your doctor or midwife.

Infections transmitted by animals

Cats Cats faeces can contain an organism which causes toxoplasmosis. Avoid emptying cat litter trays while you are pregnant. If no one else can do it, use disposable rubber gloves. Trays should be cleaned daily and filled with boiling water for five minutes. Avoid close contact with sick cats and wear gloves when gardening even if you dont have a cat in case the soil is contaminated with faeces. Wash your hands and gloves after gardening. If you do come into contact with cat faeces, make sure that you wash your hands thoroughly. Follow the general hygiene rules under Preparing food (page 26).

Sheep Lambs and sheep can be a source of an organism called Chlamydia psittaci, which is known to cause miscarriage in ewes. They also carry toxoplasma. Avoid lambing or milking ewes and all contact with newborn lambs. If you experience flu-like symptoms after coming into contact with sheep, tell your doctor. Pigs Research is going on to see if pigs can be a source of hepatitis E infection. This infection is dangerous in pregnant women, so avoid contact with pigs and pig faeces. There is no risk of hepatitis E from eating cooked pork products.

INHERITED CONDITIONS
Some diseases or conditions are inherited from one or both parents. These include cystic fibrosis, haemophilia, muscular dystrophy, sickle cell disorders and thalassaemia. If you, your babys father or any of your relatives has an inherited condition or if you already have a baby with a disability, talk to your doctor. You may be able to have tests early in pregnancy to check whether your baby is at risk or affected (see page 49). Ask your GP or midwife to refer you to a genetic counsellor (a specialist in inherited diseases) for advice. Ideally, you should do this before you get pregnant or in the early weeks of pregnancy.

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WORK HAZARDS
If you work with chemicals, lead or X-rays, or in a job with a lot of lifting, you may be risking your health and the health of your baby. If you have any worries about this, you should talk to your doctor, midwife, occupational health nurse, union representative or personnel department. If it is a known and recognised risk, it may be illegal for you to continue, and your employer must offer you suitable alternative work on the same terms and conditions as your original job. If no safe alternative is available, your employer should suspend you on full pay (give you paid leave) for as long as necessary to avoid the risk. If your employer fails to pay you during your suspension, you can bring a claim in an employment tribunal (within three months). This will not affect your maternity pay and leave. See also pages 168169.

Computer screens
The most recent research shows no evidence of a risk from visual display units on computer terminals and word processors.

You can buy a pair of support stockings in the pharmacy over the counter, which will reduce leg swelling. Before you travel, think about your destination. Could you get medical help if you needed it? Are any immunisations needed which might be harmful to the pregnancy? If you are travelling to Europe, make sure that you have a European Health Insurance Card (formerly known as E111), which entitles you to free treatment while abroad. You can get this from: a post office by calling 0845 606 2030, or from www.ehic.org

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YOUR HEALTH IN PREGNANCY

FLYING AND TRAVEL

Flying is not harmful for you or your baby, but some airlines will not let you fly towards the end of your pregnancy, and you should check conditions with them.

Coping at work
You might get extremely tired particularly in the first few and last few weeks of your pregnancy. Try to use your lunch break to eat and rest, not to do the shopping. If travelling in rush hour is exhausting, ask your employer if you can work slightly different hours for a while. Dont rush home and start another job cleaning and cooking. If you have a partner, ask them to take over. If you are on your own, keep housework to a minimum, and go to bed early if you can. Your rights to antenatal care, leave and benefits are set out in Chapter 17.

Long distance travel (longer than five hours) carries a small risk of thrombosis (blood clots) in pregnant women. If you fly, drink plenty of water to stay hydrated and do the recommended calf exercises.

Safety on the move Road accidents are among the most common causes of injury in pregnant women. To protect yourself and your baby, always wear your seatbelt with the diagonal strap across your body between your breasts and with the lap belt over your upper thighs. The straps should lie above and below your bump, not over it.

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